Question 16

A patient is admitted intubated and ventilated with massive haemoptysis.

a) List the investigations that will assist with localizing the site of bleeding. Include the advantages and limitations of each investigation in your answer. (50% marks)

b) A single active bleeding site is found to originate from the left lung. Discuss the specific management options for the bleeding. (50% marks)

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College answer

The role of rigid bronchoscopy was not listed as an option in many candidates' answers, and there was also a lack of consideration for the different sided DLTs for several candidates. The clinical scenario presented was urgent and many candidates listed investigations which would have led to patient detriment e.g. MRI. Many candidates answered part b) with the management of coagulopathy when specific management of an isolated bleeding site was required. Clinical management and the answers in the part 2 CICM exam often require context, and this is no different in the vivas and clinical cases, and there are further comments to  demonstrate this later in the report.

Discussion

Quite right, to send the patient choking on blood into the MRI scanner should be viewed as a huge blunder of airway etiquette, and would have led to some low marks in this SAQ. Some may consider this as a critical failure point, i.e. where the answer is dangerous in some fundamental way, and should not pass even though the rest of the points mentioned are technically valid. 

a) Investigations:

Investigation Advantages Disadvantages
CXR Ubiquitous, easily available
Already necessary for intubated patients
Also confirms ETT position
Minimal radiation exposure
Poor accuracy
Cannot localise source of bleeding beyond lobes
Non-contrast CT Can reveal the causal pathology (eg. abscess)
Can localise the bleeding site (eg. area of ground glass)
No contrast exposure
May not identify bleeding vessels
Risk of transport
 
CT angiogram Highly accurate for localising the site of bronchial arterial bleeding
 
Risk of transport
May not identify endobronchial lesions in the presence of clot
Bleeding rate would have to be considerable to be able to visualise extravasation
Digital subtraction angiography Able to perform embolisation in the same procedure
May define the feeding vessels of an AVM or tumour
Large contrast and radiation exposure
On its own, may not be able to find the lesion (i.e. best when combined with CTA)
 
Fiberoptic bronchoscopy Able to localise the source of bleeding when it is endobronchial
Offers various endoluminal management options
Able to clear the airway
Blood may obscure the view
Clots may be too large to suction
May not be able to identify a very distal lesion, or define an extrabronchial pathology
May cause more bleeding

b) Management options:

1) Achieve lung isolation

  • Intubate the patient with a large-bore endotracheal tube to permit bronchoscopy
    • And position the patient in a lateral position with the bleeding lung dependent
  • Or: introduce a bronchial blocker and inflate the balloon in the main bronchus of the affected lung
  • Or: intubate the patient with a double-lumen endotracheal tube
    • For a bleed originating in the left main bronchus, a right-sided DLT is called for, as a left-sided DLF would not permit surgical or bronchoscopic access
    • For any other site of bleeding a left-sided DLT would be appropriate and much easier to place
    • Some authors argue that these devices are not useful because the small aperture of each lumen does not allow the passage of a "proper" bronchoscope, of the sort that has ample instrument or suction ports.

2) Trial conservative management: 

  • Nebulised tranexamic acid 
  • Nebulised adrenaline
  • Ice saline lavage

3) Interventional bronchoscopy techniques

  • Adrenaline injections
  • Various gels, foams, sealants (including thrombin slurry)
  • Temporary silicone plugs  
  • Temporary bronchial stents
  • Nd:YAG laser
  • N-butyl cyanoacrylate glue

4) Rigid bronchoscopy techniques 

  • Argon plasma coagulation
  • Electrocautery
  • The placement of larger stents
  • The retrieval of larger clots

5) Interventional radiology

  • Bronchial artery embolisation (coils, foam, glue, PVC particles)

6) Surgery is the last option:

  • Lobectomy and pneumonectomy are often required
  • The only option for pulmonary arterial or venous bleeding, and probably the preferred option for malignancies and large abscesses.

References

Adlakha, Amit, et al. "LONG-TERM OUTCOME OF BRONCHIAL ARTERY EMBOLISATION (BAE) FOR MASSIVE HAEMOPTYSIS.Thorax (2011).

Talwar, D., et al. "Massive hemoptysis in a respiratory ICU: causes, interventions and outcomes-Indian study." Critical Care 16.Suppl 1 (2012): P81.

Sakr, L., and H. Dutau. "Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management." Respiration 80.1 (2010): 38-58.

Ibrahim, W. H. "Massive haemoptysis: the definition should be revised." European Respiratory Journal 32.4 (2008): 1131-1132.

Corey, Ralph, and Khin Mae Hla. "Major and massive hemoptysis: reassessment of conservative management." The American journal of the medical sciences 294.5 (1987): 301-309.

Amirana, M., et al. "An Aggressive Surgical Approach to Significant Hemoptysis in Patients with Pulmonary Tuberculosis 1, 2, 3." American Review of Respiratory Disease 97.2 (1968): 187-192.

Seon, Hyun Ju, Yun-Hyeon Kim, and Yong-Soo Kwon. "Localization of bleeding sites in patients with hemoptysis based on their chest computed tomography findings: a retrospective cohort study." BMC Pulmonary Medicine 16.1 (2016): 1-6.

Kathuria, Hasmeena, et al. "Management of life-threatening hemoptysis." Journal of intensive care 8.1 (2020): 1-9.

Revel, Marie Pierre, et al. "Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis?." American Journal of Roentgenology 179.5 (2002): 1217-1224.

Remy-Jardin, Martine, et al. "Bronchial and nonbronchial systemic arteries at multi–detector row CT angiography: comparison with conventional angiography." Radiology 233.3 (2004): 741-749.

Davidson, Kevin, and Samira Shojaee. "Managing massive hemoptysis." Chest 157.1 (2020): 77-88.

Wand, Ori, et al. "Inhaled tranexamic acid for hemoptysis treatment: a randomized controlled trial." Chest 154.6 (2018): 1379-1384.

Cutshall, Danica M., Brannon L. Inman, and Melissa Myers. "Treatment of Massive Hemoptysis with Repeated Doses of Nebulized Tranexamic Acid." Cureus 14.9 (2022).

Thomas, Angela, and Gerry Lynch. "Management of massive haemoptysis." (2011).

Venkatesh, A. N., and H. Rajanna. "MANAGEMENT OF HEMOPTYSIS IN EMERGENCY ROOM." Вестник экстренной медицины 14.1 (2021): 44-50.

McKee, Andrew. "Massive Hemoptysis." Cardiothoracic Critical Care E-Book (2007): 392.

Haponik, Edward F., Alan Fein, and Robert Chin. "Managing life-threatening hemoptysis: has anything really changed?." Chest 118.5 (2000): 1431-1435.

Sampsonas, F., et al. "Bronchoscopic, non-interventional management of hemoptysis in resource limited settings: insights from the literature." Eur Rev Med Pharmacol Sci 24.7 (2020): 3965-3967.

Valipour, Arschang, et al. "Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis." Chest 127.6 (2005): 2113-2118.

Sakr, L., and H. Dutau. "Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management." Respiration 80.1 (2010): 38-58.